Should Surgical Services Admit Small Bowel Obstructions Managed Non-operatively?

INTRODUCTION: Over the past decade, small bowel obstructions (SBO) have been increasingly managed non-operatively. Prior studies have looked at outcomes based on admission to surgical services (SS) or medicine services (MS), but most are restricted to operative patients. This study evaluates the outcomes of non-operative patients specifically. METHODS: A 12-year retrospective cohort study of patients ≥18-years-old admitted with SBO within one healthcare system was performed. Only non-operative patients were included. Clinicodemographic characteristics and admission details were extracted from the electronic medical record. Statistical analysis was performed using the student's t-test, chi-square, and multivariable regression. RESULTS: A total of 3278 patients were included, of which 933(28.4%) patients were admitted to a SS. MS patients were older (57.7 vs 54.7 years, P < .001) and more likely to have diabetes (24.1 vs 20.2%, P = .015), CHF (5.7 vs 3.1%, P = .002), and AKI (29.8 vs 16.7%, P < .001). SS patients were more likely to have cancer (19.3 vs 13.7%, P < .001). Univariate analysis showed admission to SS decreased length of stay (3.4 vs 4.1 days, P < .001) and index admission mortality (0.1 vs 2.2%, P < .001). On multivariable analysis, admission to a SS decreased admission mortality (OR 0.056), 30-day mortality (OR 0.15), and 180-day mortality (OR 0.307). Similarly, 30-day readmissions (OR 0.683) and 180-day readmission (OR 0.54) were also significantly decreased. Length of stay was decreased by .6 days (P < .001). DISCUSSION: In patients with non-operative SBO, admission to a surgical service decreased length of stay, mortality, and readmission. Further work should be completed evaluating how increased comorbidities affect long term outcomes. However, significantly decreased length of stay and mortality continue to support surgical services admitting SBO patients.

Admitting Service and Outcome for Small Bowel Obstruction.

INTRODUCTION: Small bowel obstruction (SBO) is a common admission diagnosis. Prior research has shown improved length of stay and time to operation for SBO patients on surgical services (SS) compared to medical services (MS). This study evaluates the impact of admitting service on readmission and mortality. METHODS: A 12-year retrospective cohort study of patients ≥18 years old, admitted with SBO to either a MS or SS within one health care system was performed. Clinicodemographic characteristics and admission details were extracted and reviewed. Statistical analyses performed included the Student's t-test, chi-square, and multivariable regression. RESULTS: The study included 7921 patients, of which 3862 (48.8%) were admitted to a SS. No significant clinicodemographic differences existed between the groups except SS patients were more likely to have cancer (23.3% vs 15.2%, P < .0001) and to be within a 30-day post-operative period (9.4% vs 1.8%, P < .0001). On multivariable analysis, admission to a SS was associated with a decreased admission mortality (OR .70), 30-day mortality (OR .42), and 180-day mortality (OR .42). 30-day readmissions (OR .54) and 180-day readmission (OR .43) were also significantly decreased for SS patients. In patients requiring a procedure during admission, there was significantly decreased admission mortality (OR .684), 30-day mortality (OR .470), 180-day mortality (OR .431), 30-day readmission (OR .63), and 180-day readmission (OR .50). CONCLUSION: In patients with SBO, admission to a SS confers decreased odds of readmission and mortality compared to MS. Future studies are needed to understand the management decisions potentially underlying these differences. These findings may help better define admission pathways and improve outcomes.

General Surgery Residency Application Evaluation in a USMLE Step 1 Pass/Fail World: A Retrospective Comparison.

Introduction The United States Medical Licensure Exam (USMLE) Step 1 has been used as both a licensing exam and a way for residency programs to evaluate applicants. It has had significant impact upon the match process over time. With the 2020 decision to make the exam pass/fail due to its unclear validity as an evaluation for future physician performance, programs will go through the match without the Step 1 score. We set out to better understand the effects of the exam score on our selection process, with the hypothesis that without the step 1 score, the ranking of our applicants would be significantly altered. Methods We performed a retrospective analysis of applications to a single General Surgery residency program with 4 categorial residents per year at a physician led, academic, tertiary care medical center from 2017-2020. Important applicant factors including USMLE Step 1 and 2, AOA status, science grades, clerkship scores, audition rotations, volunteer activities, research activities, letters of recommendation, and personal statements were given points and evaluated through our equation, the sum of which was used to create a rank list and offer interviews. The standard deviation of scores was calculated with and without Step 1, and the distribution of scores compared. The range and average of applicants' change in point scores were examined. Results The applications of 653 students were reviewed. After removal of USMLE step 1 points, 40% of all applicants decreased in rank, 35% remained the same, and 24% increased. Specifically, 18.8% of the top third dropped to the middle third, and 11.7% of the bottom third jumped to the middle third, while the middle third changed little (0.2% dropped and 0.9% jumped out of middle third). The points given for USMLE step 1 created a wider distribution of scores with a negative skewness, suggesting there were more applicants below the mean than above. After removing those points, applicants' scores had a narrower distribution and skewness closer to 0, showing fewer upper outliers and more applicants near the mean. Conclusions The USMLE Step 1 score significantly affected the evaluation of applicants, and the removal of it from the recruitment criteria tightened applicant rankings. The elimination of the USMLE Step 1 score in the assessment of applicants will allow for its replacement with variables that better reflect the core values of residency programs.

Expansion of Surgical Graduate Medical Education Training Programs: A Return on Investment Analysis.

BACKGROUND: The productivity of surgical departments is limited by the staffing of attending surgeons as well as surgical residents. Despite ongoing surgeon shortages, many health care organizations have been reluctant to expand training programs because of concerns about cost. We sought to determine the return on investment for the expansion of surgical training programs within our health system. METHODS: This study was completed as a retrospective review comparing two independent surgical departments at separate hospitals within a single integrated health system, including complete fiscal information from 2012 to 2019. Hospital A is a 594-bed hospital with large growth in its graduate surgical training programs over the study's period, whereas Hospital B is a 320-bed hospital where there was no expansion in surgical education initiatives. Case volumes, the number of full-time employees (FTE), and revenue data were obtained from our health systems business office. The number of surgical trainees, including general surgery residents and vascular surgery fellows, was provided by our office of Graduate Medical Education. The average yearly net revenue per surgeon was calculated for each training program and hospital location. RESULTS: Our results indicate a positive association between the number of surgical trainees and departmental net revenue, as well as the annual revenue generated per physician FTE. Each additional ancillary provider per physician FTE resulted in a positive impact of $112,552-$264,003 (R2 of 0.69 to 0.051). CONCLUSIONS: Regardless of hospital location or surgical specialty, our results demonstrate a positive association between the average net revenue generated per surgeon and the number of surgical trainees supporting the department. These findings are novel and provide evidence of a positive return on investment when surgical training programs are expanded.

The Value of Surgical Graduate Medical Education (GME) Programs Within An Integrated Health Care System.

OBJECTIVE: Surgical graduate medical education (GME) programs add both significant cost and complexity to the mission of teaching hospitals. While expenses tied directly to surgical training programs are well tracked, overall cost-benefit accounting has not been performed. In this study, we attempt to better define the costs and benefits of maintaining surgical GME programs within a large integrated health system. DESIGN: We examined the costs, in 2018 US dollars, associated with the surgical training programs within a single health system. Total health system expenses were calculated using actual and estimated direct GME expenses (salary, benefits, supplies, overhead, and teaching expenses) as well as indirect medical education (IME) expenses. IME expenses for each training program were estimated by using both Medicare percentages and the Medicare Payment Advisor Commission study. The projected cost to replace surgical trainees with advanced practitioners or hospitalists was obtained through interviews with program directors and administrators and was validated by our system's business office. SETTING: A physician lead, integrated, rural health system consisting of 8 hospitals, a medical school and a health insurance company. PARTICIPANTS: GME surgical training programs within a single health system's department of surgery. RESULTS: Our health system's department of surgery supports 8 surgical GME programs (2 general surgery residencies along with residencies in otolaryngology, ophthalmology, oral-maxillofacial surgery, urology, pediatric dentistry, and vascular surgery), encompassing 89 trainees. Trainees work an average of 64.4 hours per week. Total health system cost per resident ranged from $249,657 to $516,783 based on specialty as well as method of calculating IME expenses. After averaging program costs and excluding IME and overhead expenses, we estimated the average annual cost per trainee to be $84,171. We projected that replacing our surgical trainees would require hiring 145 additional advanced practitioners at a cost of $166,500 each per year, or 97 hospitalists at a cost of $346,500 each per year. Excluding overhead, teaching and IME expenses, these replacements would cost the health system an estimated additional $16,651,281 or $26,119,281 per year, respectively. CONCLUSIONS: Surgical education is an integral part of our health system and ending surgical GME programs would require large expansion of human resources and significant additional fiscal capital.

Exploring intended infant feeding decisions among low-income women.

BACKGROUND: Low-income women have the lowest rates of breastfeeding in the United States. Greater understanding of factors that predict intention to feed artificial breastmilk substitute is needed to inform the design and timing of interventions to promote breastfeeding among vulnerable women. This study aimed to identify demographic and reproductive characteristics and other factors associated with intent to feed artificial breastmilk substitute among low-income women. MATERIALS AND METHODS: Data from 520 low-income women interviewed at 24-41 weeks of gestation during enrollment in a prenatal breastfeeding education intervention study were analyzed. Participant characteristics, reasons for feeding decision, and sources and types of information received were compared among women intending to feed only artificial breastmilk substitute and other women. RESULTS: Most participants (95%) had already chosen an infant feeding method at the time of interview. There were no differences in plans to return to work by feeding plan. Women reporting intention to feed only artificial breastmilk substitute were less likely to report receiving information about the benefits of breastfeeding, how to breastfeed, and pumps and were more likely to cite personal preference and convenience as reasons for their decision. Women were more likely to intend to feed artificial breastmilk substitute if they had a previous live birth or had not breastfed a child, including the most recent. CONCLUSIONS: These findings suggest breastfeeding promotion should target women early and include sensitive, effective ways to promote breastfeeding among women who have not previously successfully breastfed. Breastfeeding history should be elicited, and plans to pump should be supported prenatally.